trach MTL 4 1 1 Tracheostomy Tubes: Managing Communication and Swallowing Issues Carmin Bartow, MS, CCC-SLP, BRS-S Speech Pathologist Vanderbilt University Medical Center Nashville, TN Disclosure Statement Disclosure: Financial — Received a speaking fee from Passy-Muir, Inc. for this presentation Nonfinancial — No relevant nonfinancial relationship exists. 2 3 Objectives Describe changes in physiology after tracheotomy regarding speech, swallowing and respiration Differentiate between various communication options for trach and vent dependent patients Determine the most appropriate swallowing evaluation and treatment techniques for trach and vent dependent patients Describe how the Passy-Muir Speaking Valve works and explain the physiologic benefits of the valve
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trach MTL 4 1
1
Tracheostomy Tubes:
Managing Communication and
Swallowing Issues
Carmin Bartow, MS, CCC-SLP, BRS-S
Speech Pathologist
Vanderbilt University Medical Center
Nashville, TN
Disclosure Statement
� Disclosure: Financial — Received a
speaking fee from Passy-Muir, Inc. for this
presentation
� Nonfinancial — No relevant nonfinancial
relationship exists.
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3
Objectives
� Describe changes in physiology after tracheotomy regarding speech, swallowing and respiration
� Differentiate between various communication options for trach and vent dependent patients
� Determine the most appropriate swallowing evaluation and treatment techniques for trach and vent dependent patients
� Describe how the Passy-Muir Speaking Valve works and explain the physiologic benefits of the valve
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Topics
� Trach overview
� Communication Options
� Passy-Muir Speaking Valves
� Mechanical Ventilation
� Dysphagia Management
� Conclusion / Hands-on time
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Tracheostomy Overview
�Tracheostomy Tubes
�Physiologic Changes after
Tracheotomy
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Tracheotomy
Indications for tracheotomy
� Prolonged intubation
� Need for long term mechanical ventilation
� Need for permanent tracheostomy tube
� Upper airway obstruction / edema
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Trach Tube Components
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Tracheostomy Tube
Inflated Cuff
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Tracheostomy Tube
Deflated Cuff
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Tracheostomy Tube
Over-inflated cuff
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Trach Tubes - Shiley
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Trach Tubes - Bivona
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Trach Tubes – Portex
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Trach Tubes – Jackson Metal
Physiologic Changes after
Tracheotomy
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Physiologic Changes after
Tracheotomy
� Respiration – breathing
in and out through trach
tube
� Speech – inability to
produce phonation due
to lack of airflow
through vocal folds
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Physiologic Changes after
Tracheotomy� Smell/taste – decreased
sense of smell and taste due
to lack of airflow into upper
airway
� Secretion management –
inability to mobilize
secretions effectively due to
decreased cough effort
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Physiologic Changes after
Tracheotomy
Swallowing – many research studies regarding trach tubes and swallowing report a negative impact on swallowing efficiency
�Aspiration
�Pressure Differences
�Airflow Differences
�Cuff issues
�Laryngeal Sensitivity
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Aspiration
� An association b/t aspiration and trachs has been well documented
� Trach associated with increased risk of aspiration and pneumonia (Muz et al, 1987)
� Delayed laryngeal vestibule closure which was associated with tracheal aspiration (Abraham and Wolf, 2000)
� Disruption of vocal fold function (Nash 1988, Shaker, 2000)
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Pressure Differences
� Aerodigestive tract is a set of tubes and valves (Logemann, 1988); swallowing is a pressure driven event
� There is an inability to build up adequate pressure to propel the bolus through the pharynx with an open trach (Eibling and Gross, 1996)
� When subglottic pressure is altered with a trach, neuroregulation of pharyngeal swallow physiology
is likewise altered (Gross, et al, 2003)
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Airflow differences
� The loss of expiratory airflow through the
upper airway for normal respiration has
been linked to increased pooling of
secretions within the larynx and pharynx
(Siebens, et al, 1993)
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Cuff issues
�Reduced laryngeal elevation and silent
aspiration were significantly higher in
cuff inflated vs. cuff deflated condition
(Logemann, 2005)
� The cuff DOES NOT prevent aspiration
(Ross & White, 2003); it is not
“watertight”
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Laryngeal sensitivity
� Normal laryngeal sensitivity = Cough
� Trach tubes result in reduced pharyngeal /
laryngeal sensation (Tippet et al, 1991)
VFSS - aspiration
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Communication Options
� Non-Verbal: writing, AAC, communication board,
mouthing
� Verbal
� Leak speech
� Finger occlusion
� Talking trach
� Speaking valves
� Plugging / capping
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Leak Speech
� Ability to produce voice with airflow “leaking” around a trach tube into upper airway
� Occurs most often with cuffless tubes, deflated cuffs or fenestrated trachs
� Airflow takes path of least resistance through trach tube typically making speech breathy and weak